Institutional Equity & Compliance
EMPLOYEE Request for Disability-Related Accommodation
The information requested below is CONFIDENTIAL and will be used to determine an appropriate reasonable accommodation for your work-related limitations due to a qualifying disability. Please see important note at bottom of page regarding disclosure of genetic information.
This form is to be completed by the employee or a representative acting on behalf of the employee, and provided to the Office of Institutional Equity & Compliance, Student Services West Building, Level 2. Phone (909) 869-4646, Email
Employee Information
Name: / Department:Work Phone: / Home Phone: / Email Address:
Job Title: / Bargaining Unit/ Employee Group / Supervisor
information related to accommodation request
Indicate if your disability or medical condition is: / Permanent / Temporary / Of Undetermined DurationIf Temporary, please state the anticipated recovery date:
FUNCTIONAL LIMITATIONS
(Check the major activity or activities you believe to be limited by your disability)
Walking / Breathing / Seeing / Working
Hearing / Learning / Talking / Performing Manual Tasks
Other (Please specify):
ACCOMMODATION REQUESTED
(Please be specific and attach additional sheets if necessary.)
ESSENTIAL JOB FUNCTION(S) FOR WHICH ACCOMMODATION IS BEING REQUESTED:
(Please be specific; e.g., filing, using copier, etc., and attach additional sheets if necessary.)
DESCRIBE HOW THE PROPOSED ACCOMMODATION WOULD ALLOW YOU TO PERFORM THE ESSENTIAL FUCTIONS OF YOUR JOB: (Please attach additional sheets if necessary)
EMPLOYEE VERIFICATION and Signature
I verify that the above information is correct and to the best of my knowledge. I am requesting a reasonable accommodation which will allow me to perform the essential functions of my position as described above.
Signature: / Date:
dean, director, or department designee
Signature / Date:
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. “Genetic information” as defined by GINA, includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the fact than an individual or an individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.
January 2019